A high-stakes contract negotiation between Duke Health and insurance administrator Aetna is approaching a critical deadline, threatening to disrupt healthcare access for thousands of North Carolina residents, including state employees. If an agreement on reimbursement rates is not reached by October 19, Duke Health facilities and physicians could become out-of-network, leading to significantly higher medical bills for many patients.
The dispute centers on financial terms, with Duke Health seeking increased payment rates to cover rising operational costs, while Aetna aims to control healthcare expenses for its members. The outcome will directly impact patients covered by Aetna, including those under the North Carolina State Health Plan.
Key Takeaways
- The current contract between Duke Health and Aetna is set to expire on October 19, 2025.
- Failure to reach a new agreement will move Duke Health to out-of-network status for Aetna members.
- The dispute revolves around reimbursement rates, which Duke Health claims have not been adjusted in four years despite inflation.
- Thousands of North Carolina state employees are among those who could be affected by higher out-of-pocket costs.
- State officials are preparing contingency plans to help affected health plan members find alternative in-network care.
The Financial Disagreement at the Center of Negotiations
The core of the conflict is a disagreement over how much Aetna should pay Duke Health for medical services. Both organizations have publicly stated their positions as the deadline approaches, highlighting the financial pressures within the U.S. healthcare system.
Duke Health's Position on Rising Costs
Duke Health officials argue that the negotiations are necessary to secure fair compensation that reflects the actual cost of providing care. In a public statement, the health system emphasized that it has not received a rate increase from Aetna in four years, a period during which costs for pharmaceuticals, medical supplies, and labor have risen sharply.
"Our goal is to secure fair and sustainable reimbursement rates that reflect the true cost of delivering high-quality care," Duke Health stated. "We are asking for modest increases that are less than the rate of inflation."
The health system maintains that the requested adjustments are not about profit but are essential for maintaining the quality of care for Aetna patients without disruption. They also noted their willingness to engage in value-based reimbursement models, which reward providers for efficiency and quality outcomes.
Aetna's Stance on Affordability
Aetna, which serves as the third-party administrator for the State Health Plan, has framed its position around protecting its 1.5 million members in North Carolina from escalating healthcare costs. The insurer noted that provider payments are a direct driver of health insurance premiums.
"Aetna is committed to providing access to affordable, quality health care for our 1.5 million members in North Carolina," an Aetna spokesperson said. "We have a responsibility to offer a cost effective, quality provider network to our customers."
The company highlighted that North Carolina already has some of the highest healthcare costs in the country and that it is working to prevent further increases for its members. Aetna confirmed that discussions are ongoing and that their goal is to reach a "mutually agreeable outcome" with Duke Health.
Impact on Thousands of North Carolina Patients
Should the October 19 deadline pass without a resolution, thousands of individuals and families will face difficult choices regarding their medical care. The most immediate consequence would be the reclassification of Duke Health as an out-of-network provider.
What Out-of-Network Status Means for Patients
For patients with Aetna insurance, an out-of-network provider is one that has not agreed to the discounted rates negotiated by the insurer. Seeking care at an out-of-network facility typically results in:
- Higher Co-pays and Coinsurance: Patients are responsible for a larger percentage of the bill.
- Separate Deductibles: Many plans have a much higher deductible for out-of-network care, or it may not apply at all.
- Balance Billing: Patients may be billed for the difference between what the provider charges and what Aetna agrees to pay.
This potential for unexpected and substantial medical bills is a primary concern for families who rely on Duke Health for routine and specialized care.
State Health Plan Prepares for Disruption
The North Carolina State Health Plan's Board of Trustees met to address the potential impact on state employees. Recognizing the possibility of a failed negotiation, the board adopted a resolution allowing plan staff to actively assist members in transitioning to new, in-network healthcare providers if necessary.
State Treasurer Brad Briner, speaking at the board meeting, placed the responsibility for a potential out-of-network scenario on the healthcare provider. "Duke is demanding a significant raise off the back of our hardworking state employees," Briner said. "If we end up out of network, Duke is the one who made that choice."
Protections for Patients in Active Treatment
While many patients face uncertainty, North Carolina state law provides protections for individuals in the middle of a specific course of treatment. These provisions ensure continuity of care for the most vulnerable patients, even if their provider leaves their insurance network.
According to a State Health Plan board member, approximately 2,800 members are currently undergoing a course of treatment at Duke Health. This group primarily includes cancer patients and individuals in maternity care.
"For the foreseeable future, they will continue to see Duke Health on an in-network basis," the board member explained. "They will not be turned away, but there is some paperwork that’s required to do that."
These continuity of care protections are designed to prevent dangerous interruptions in treatment. However, affected patients will need to proactively complete the necessary forms with the State Health Plan to ensure their in-network benefits continue without issue after the contract deadline.
As the October 19 deadline looms, patients, state officials, and employers are watching closely. The outcome of the negotiations between Duke Health and Aetna will serve as a significant indicator of the ongoing tensions between healthcare providers and insurers over the rising cost of medical care in the United States.
